Patient Information Sheet
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1PATIENT INFORMATION SHEET
(Please fill out completely)
Date ______________
Patient’s Information
Name _____________________________________________ Social Security # _______________
Last
First
Middle Initial
Street Address ____________________________________________Date of Birth _____________
___________________________________________________Home Phone (___)______________
City
State
Zip
Employer ________________________________________________________________________
Name
Address
Phone #
____________________________________ □ I like to receive correspondences via email
E-Mail
:
Spouse □ or Parent Information □
Name _____________________________________________ Social Security # _______________
Last
First
Middle Initial
Home Phone (___)______________ Date of Birth _____________
Employer ________________________________________________________________________
Name
Address
Phone #
:____________________________________ □ I like to receive correspondences via email
E-Mail
Name of Responsible Party ______________________________________ Relationship_____________
Last
First
Middle Initial
How Did You Hear of Our Office?
□
□
□
Web Search
Phonebook
Co-Worker or Friend/Family
_____________________________
□
□
Do You Have Insurance?
Yes
No
1. Insurance Co. Name ______________________________Mailing Address _____________________
Subscriber # ________________________________Group # ___________________________
Subscriber Name ____________________________Relationship ________________________
Subscriber’s Employer___________________________________________________________
2. Secondary Insurance Co. Name _____________________Mailing Address _____________________
Subscriber # ________________________________Group # ___________________________
Subscriber Name ____________________________Relationship ________________________
Subscriber’s Employer___________________________________________________________
I understand that responsibility for dental services provided in this office for myself or my dependents,
regardless if covered by insurance, is mine.
Signature _______________________________
TROY FAMILY DENTAL
JD Troy, D.D.S., P.L.L.C
1516 Hudson St., Suite 101
Longview, WA 98632
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Parent category: Medical